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The notice on the clinic’s website, “We do not accept Medicaid,” might as well say, “Poor people aren’t welcome here.” It’s an unfortunate practice that is sadly all too common and affects the lives of millions of Americans. My patient, Gerald, is one of them.

A retired school bus driver, Gerald and his wife make do on a meager income. For health insurance, he relies on Medicaid — insurer of the aged and disabled, pregnant women and children, and the poor. Gerald drives 50 miles into the city to see me for his diabetes. There are clinics closer to his home, of course, but he makes the long journey to see me because the clinics in his area won’t see patients with his insurance. In our health care system, beggars can’t be choosers.

The blanket refusal of many physicians to see patients with Medicaid is unjust. It contributes to a health care system of separate but equal based on social class. The medical profession must fix this glaring breach in our contract with society — all physicians should accept Medicaid.

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An oft-cited study showed that 31 percent of physicians nationwide were not willing to accept new Medicaid patients. The rate was even higher for orthopedic surgeons and dermatologists, two of the highest-paying specialties in medicine. The Affordable Care Act led to some modest improvements, particularly in access to primary care, but the acceptance rate of patients covered by Medicaid remains dismally low.

Yet these patients need us. One in 10 have cancer; 1 in 5 have diabetes; 1 in 3 have mental illness. As Paul Farmer has written, disease has a “preferential option for the poor.”

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To explain why some physicians do not accept Medicaid patients, physicians and administrators frequently blame the bureaucratic hassles of Medicaid, particularly its subpar reimbursements. Nationally, Medicaid reimburses providers for their services at 66 percent the rate of Medicare and at even lower than that compared to private insurance. So the business argument goes like this: To maximize revenue and margins, prioritize patients with private insurance and turn away those with Medicaid.

Patients with Medicaid are also often psychosocially complex, requiring more attention and resources than the average patient. Gerald, for example, can’t read, which complicates and frustrates his care. So the job satisfaction argument goes like this: To minimize encounters with difficult patients, prioritize those with private insurance and turn away those with Medicaid.

What this means for patients with Medicaid is what Seema Verma, administrator for the Centers for Medicare and Medicaid Services, decries as a “card without care.” In truth, that’s a bit misleading. Gerald does have access to care — he sees me. A survey of Medicaid enrollees found that 84 percent were able to get the care they needed. Yet to do that Gerald must drive past dozens of other clinics that will not accept Medicaid and get to a safety-net clinic that will.

Although Medicaid helps bridge the gap between those who have private insurance and those who have no insurance, physicians drive a wedge into the health care system and propagate the structural inequities of separate but equal when they turn away those with Medicaid.

A modern version of the Hippocratic oath, called “Medical Professionalism in the New Millennium: A Physician Charter,” demands that we work to “eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.” That’s only fair. In recognition of the integral role that physicians play in society, the U.S. government invests $15 billion each year in the training of doctors, or $150,000 per year on each and every resident physician. No other profession enjoys this level of public support.

To rebuff Medicaid, the insurer of society’s most underprivileged and vulnerable, is to reject our moral responsibility as physicians and to worsen the very disparities in health care we have been charged with eliminating.

While policymakers continue to work towards improving Medicaid, physicians can and must do their part to live by our collective professional ethics and help those most in need of our services. Doing so would not bankrupt our practices. Each physician can decide what level his or her practice can sustain — the answer is not zero.

Over the last few years, Medicaid and health care have become increasingly politicized. But physicians must remember that behind all the double-speak, pretense, and charades are real people like Gerald who need care. Refusing to see them is nothing less than discrimination by another name.

Sumit Agarwal, M.D., is a fellow in internal medicine at Brigham and Women’s Hospital and is pursuing a master’s degree in public health from the Harvard T.H. Chan School of Public Health.

  • Mo
    Spot on in concept. There is NO doubt that MANY Medicaid (read Welfare to those in states that use different wording) take advantage of the system to the furthest extent possible
    My wife was at the supermarket last week and said that a women with several younger children checking out in front of her. The entire family was mannerly and well groomed and then the shocker the women put up 3 packages of Lobster tails Colossal Shrimp and a full uncut filet mignon (tenderloin) and you guessed it paid for the order with FOOD STAMPS (e-card)
    So is this racism? NOPE, they were white. Is it some sort of bias? Nope, they were not doing anything to draw attention to, being rude, acting up, or being belligerent just simply taking advantage of the rest of us who paid the taxes so she could eat better than all of us. Bill was close to $200 for this simple 3 dishes.
    There have been MANY MANY studies done on the other side as well.
    Welfare patients have the highest number of missed appointments and the lowest compliance rates of any other demographic in the US Population. Basically, they want to be cared for when they want it and then they are selective as to what they opt to follow as advice even if not doing so is detrimental because they know that the system will fix it later on as well so why bother being compliant
    The issue was ALWAYS said that Medicare pays you enough to break even with NO money to take home while Medicaid pays you less than your overhead so for each one you see it costs you money out of your pocket (otherwise a federally/state based doctor supplied charity system that you can’t even deduct the charity from your taxes for the donations for them)
    Yet there are other medical professionals who want this to be MANDATORY and linked to our licenses??? MASS retirement guaranteed!!
    Dr Dave

    • In Michigan they were going to tax physicians a medicaid tax of 5% per patient. I would have easily left Michigan if that actually passed. We now limit medicaid patients to 2-3 a week. If it were up to me I would have cut them out of our private practice all together. I would say 50% of the time or more I can’t even go in the room because it smells like smoke so much it makes me sick. I hate second hand smoke exposure. I have actually turned away a few patients because they smoked right before they came in and it made me dizzy.

    • If this country was actually like smart.. and I was in charge… what I would do is I would give medicaid patients an ultimatum. Either quit smoking or no medicaid. Simple. Smoking is not a medication, not a luxury, nothing. its a burden to the rest of us. So if you want us to pay for your healthcare, stop smoking. Done.

  • Amazon is a luxury, not a privilege! And if you dont know the difference then you pay my taxes for medicaid so I dont have to!

  • I had one medicaid patient recently told me she spent 9500.00 for a dog. 9500! Guess whos paying for that dog.. you and I. Dont get me wrong there are some people who definitely deserve medicaid, but I think > 50% are taking advantage. So stop smoking and limit your pets!

  • I’m not a physician, but from a basic economics standpoint Medicaid reimbursement isn’t even enough to keep the lights on.. It would be great if physicians took a mix and treated a certain percent of Medicaid patients while still being able to stay solvent. That would be ideal, but shouldn’t be forced.

    • Who in their right mind would go into medicine with that as a requirement?
      I am heading into 40 years of slicing and dicing humans and have yet to participate with Medicare or Welfare
      For me the whole forced slavery concept of mandatory work for payments LOWER then my overhead is unconstitutional and yet I am sure that it is legally not if everyone agrees to it
      The point is why force substandard payments on us only to then have us render substandard care
      Aren’t the Medicare and Welfare patients worth better than that?
      If some guys can figure out how to cut enough corners to survive with them as a payer base so be it but forcing every doc to participate is NEVER going to happen and shouldn’t
      We are independently thinking 1%ers don’t try to make us union mentality laborers it simply won’t work
      I get it you see some altruistic value in treating people regardless of what it costs you but the rest of us shouldn’t be forced into your logic
      Dr. Dave
      PS I have not charged for a surgery since 2002 all my services are free the hospital charges but not me so don’t assume for a moment that I don’t give back I give FAR more then any contracted provider only I get to choose who I treat and who I don’t

  • re: dr. dave, I couldn’t agree more, that’s why i retired in 2015 after just 25 years in practice

  • @Donald Marks MD that would TRULY be the death blow the shortage of docs needs
    I can EASILY find 200 fellow colleagues who if forced to accept Medicaid Medicare would easily retire and go into either industry or just kick back and watch the system crumble
    I was asked by a few Senators last week about why the AMA hasn’t stepped into help resolve both the ACA issue and the more pressing issue with the opioid crisis and the response was because there are FAR too many guys that simply have NO clue on the bigger picture of the fact that every action somehow drives another nail in the coffin of the professiona nd eventually the industry will collapse under the weight of guys who think that we have some altruistic mandated requirement to provide care to a society if need be for free because the history books somehow positioned physians as all do gooders and not real businessmen/women
    Sorry but requiring us to accept sub-acceptable fees for our efforts is called SLAVERY no different then we had at the start of our nation only not quite as demanding and or physically evil
    Dr. Dave

    • Please forward the email addresses of the physicians you have in mind, Dr. Dave. I want to send them a happy retirement card.

  • It’s definitely a good thing they waited because after three years of a breast “tumor” you’re still alive. I’m sorry but you sound like another helpless Medicaid victim of society and this is the very reason doctors don’t like seeing Medicaid patients- always a victim of something or someone with very little proactivity to make themselves better. Cancer, unless it’s prostate cancer, doesn’t slowly grow for three years. Clearly, the tests you’ve already had show benign characteristics and the fact your still typing reconfirms it.

  • This is a horrendous, but I suspect, not uncommon situation.

    I think it’s important to separate Operations (doctors, technicians) from Admin (paper-filers and regulation-readers).

    It sounds like both teams are at fault in your description.

    But quite often, the admin side, despite the hard and caring work by an industrious few, manages to pile on delays, expense and poor outcomes onto an already challenging circumstance.

    I’m a strong believer that fewer bureaucrats equal better results. And bureaucrats tend to hog resources: money applied to a problem rarely reaches the problem intact.

    And, again, despite the dedicated few, bureaucrats of the governmental variety, unaccountable as they are, are the biggest obstacle.

    • Well written and helpful article. One way to work around this problem is to require that all practicing Physicians accept Medicare and Medicaid as a condition of licensure

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